case report disseminated intravascular coagulation after...

Case ReportDisseminated Intravascular Coagulation afterSurgery for Facial Injury

Hisashi Ozaki, Hirohiko Tachibana, Shigeo Ishikawa, Kazuyuki Yusa,Kenichirou Kitabatake, and Mitsuyoshi Iino

Department of Dentistry, Oral and Maxillofacial-Plastic and Reconstructive Surgery, Faculty of Medicine,Yamagata University, 2-2-2 Iida-Nishi, Yamagata 990-9585, Japan

Correspondence should be addressed to Hisashi Ozaki; [email protected]

Received 10 April 2016; Revised 6 May 2016; Accepted 8 May 2016

Academic Editor: Mohammad Hosein K. Motamedi

Copyright © 2016 Hisashi Ozaki et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

A case of disseminated intravascular coagulation (DIC) presenting after surgery for facial trauma associated with multiple facialbone fractures is described. With regard to the oral and maxillofacial region, DIC has been described in the literature followinghead trauma, infection, and metastatic disease. Until now, only 5 reports have described DIC after surgery for facial injury. DICsecondary to facial injury is thus rare. The patient in this case was young and had no medical history. Preoperative hemorrhage orpostoperative septicemia may thus induce DIC.

1. Introduction

Disseminated intravascular coagulation (DIC) is a dynamicpathologic process in which thrombin forms within the vas-cular system [1]. DIC is commonly associated withmalignantneoplasm,major trauma, head injury, infection, and obstetriccomplications [2]. With regard to the oral and maxillofacialregion, DIC has been described in the literature followinghead trauma, infection, and metastatic disease [3]. However,a review of literature shows only a small number of reportsdescribing DIC in relation to oral and maxillofacial surgery[4]. In particular, few reports have mentioned DIC aftersurgery for facial injury. We report herein a rare case of DICafter surgery for facial trauma associated with multiple facialbone fractures.

2. Case Presentation

A 21-year-oldmanwas brought to the emergency departmentat Yamagata University Hospital after becoming involved ina traffic accident while riding a motorbike. On arrival, hewas fully conscious and complained of facial pain. Clinicalexamination showed facial swelling, persistent intraoral andnasal hemorrhage, and bloody otorrhea from the left ear.He showed gross malocclusion associated with discontinuity

andmobilization of themaxillary andmandibular dentitions.He had no significant medical history and had been healthybefore the accident. Computed tomography (CT) and plainradiography revealed right pulmonary contusion, fractures ofa second rib and the right radius, and airway narrowing. Inthe maxillofacial region, bilateral condylar and mandibularfractures, LeFort II-type fracture, and blow-out fracture ofthe orbit were recognized (Figure 1). Airway control wasachieved by awake orotracheal intubation. Hemostasis wasperformed by suture compression for oral hemorrhage andby gauze tamponade for nasal hemorrhage under local anes-thesia, although nasal hemostasis proved extremely difficultto achieve. Respiratory management with a ventilator wasconducted under intravenous sedation until general condi-tion was stable. After another 2 days, the tracheal tube wasremoved, because no airway narrowing or obstruction wasevident. Six days after the accident, tracheotomy and reposi-tioning and fixation of the fractured facial bones, includingthe mandible, maxilla, zygoma, and blow-out fracture of theorbit, were performed under general anesthesia (Figure 1).Surgery lasted 7 h 16min, with 30mL of intraoperative bleed-ing. Intraoperatively, the patient received blood transfusion of2 units of red blood cell concentrate due to low hemoglobinlevels (7.3 g/dL).The postoperative course was uneventful. Onpostoperative day 5, however, fever over 39.0∘C and shivering

Hindawi Publishing CorporationCase Reports in DentistryVolume 2016, Article ID 6053652, 5 pageshttp://dx.doi.org/10.1155/2016/6053652

2 Case Reports in Dentistry

(a) (b)

(c) (d)

(e) (f)

Figure 1: Images from preoperative and postoperative 3D-CT. (a)–(c) showed that bilateral condylar and mandibular fractures, LeFort II-type fracture, and blow-out fracture of orbit are apparent. (d)–(f) showed that mandibular fracture was fixed by titanium plates and LeFortII-type fracture and blow-out fracture of the orbit were fixed by absorbable plates. (a) Preoperative frontal view. (b) Preoperative lateral viewof the right. (c) Preoperative lateral view of the left. (d) Postoperative frontal view. (e) Postoperative lateral view of the right. (f) Postoperativelateral view of the left.

Case Reports in Dentistry 3

Table 1: Laboratory data.

Examination First visit Preoperative POD 5 POD 6 (preshock) POD 13WBC (×103/𝜇L) 17.71 10.09 14.06 10.17 12.16RBC (×106/𝜇L) 4.69 2.33 2.91 2.7 2.55Hemoglobin (g/dL) 14.7 7.3 9.0 8.2 7.7Hematocrit (%) 44 22.3 26.4 25 24.1Platelets (×104/𝜇L) 23.8 9.8 13.1 4.6 17.5CRP (mg/dL) <0.10 3.82 12.10 23.9 4.09TBIL (mg/dL) 0.8 0.4 — 2.1 0.6Crea (mg/dL) 0.94 0.64 0.76 0.97 0.67BUN (mg/dL) 16 14 20 30 13Lactate (mmol/L) 4.07 — — 4.07 —Glucose (mg/dL) 169 — — 118 —PT (s) — 11 — 21.7 13.7PT (%) — 110 — 43 79PT-INR — 0.94 — 1.86 1.17aPTT (s) — 27.8 — 35 30.4Fbg (mg/dL) — — — 664 624FDP (𝜇g/mL) — — — 10.8 5.3D-dimer (𝜇g/mL) — — — 6.4 5.07POD: postoperative day.

were noted. Laboratory examination showed increases in thewhite blood cell count to 14,060/𝜇L and C-reactive protein(CRP) to 12.1mg/dL and a decrease in platelets to 131 × 103/𝜇L(down from 238 × 103/𝜇L at the time of the accident). CTrevealed no abnormalities other than those at the surgicalsites. The next day, the patient showed preshock status witha significant decrease in blood pressure, fever over 39.0∘C,and transient loss of consciousness. Emergency laboratorytests showed increases in CRP to 23.9mg/dL, TBIL to2.1mg/dL, creatinine to 0.97mg/dL, lactate to 4.07mmol/L,prothrombin time to 21.7 s, FDP (fibrin degradation product)to 10.8 𝜇g/mL, and PT-INR (prothrombin time-internationalnormalized ratio) to 1.86, along with a decrease in plateletsto 46 × 103/𝜇L (Table 1). The bacteria was not detected inseveral tests of blood culture. In the evaluation of respiratorysystem, PaO2 was 68.2mmHg, PaCO2 was 28.2mmHg inblood gas analysis, and PaO2/FiO2 was 341. In circulatorydynamics, noradrenaline was administered sustainably by0.04/ for keeping of blood pressure. In the evaluation ofcentral nervous system, Glasgow Coma Scale was E4V5M6and a total of 15. Therefore, SOFA (sequential organ failureassessment) score was 9. From the above results, septicshock was diagnosed and the patient was sent to the inten-sive care unit (ICU). According to the scoring algorithmcriteria established by the Japanese Association for AcuteMedicine (JAAM) for DIC [21], the patient scored 5. DICwas therefore diagnosed and treatment was initiated. To treatsevere infection, cefozopran hydrochloride and freeze-driedpolyethylene glycol-treated human normal immunoglobulinwere applied by intravenous injection empirically. A totalof 38,840 units of thrombomodulin 𝛼 was administeredfor the treatment of DIC. After another 7 days, laboratorytests showed a return to nearly normal state, with CRP of

4.09mg/dL; TBIL of 0.6mg/dL, Crea of 0.67mg/dL, WBC of12,160/𝜇L; platelet count of 175 × 103/𝜇L; prothrombin timeof 13.7 s; FDP of 5.3𝜇g/mL; and PT-INR of 1.17 (Table 1). Thepatient was thenmoved to a general ward and the subsequentcourse was uneventful.

3. Discussion

In the oral and maxillofacial region, several reports havedescribed DIC in patients with oral cancer [17], infection [11],injury [3, 13, 16, 17], orthognathic surgery [12], and toothextraction [5–10, 14, 15, 18, 19]. To the best of our knowledge,however, the English literature contains only 19 reports ofDIC in relation to oral and maxillofacial surgery except fororal cancer (Table 2). This means that DIC associated withoral and maxillofacial surgery is uncommon. Of these 19cases, the most frequent surgery associated with DIC wastooth extraction, in 10 cases. On the other hand, includingour case, only 5 cases involved facial injury related to DIC.Table 2 also shows the diseases underlyingDIC,with prostaticadenocarcinoma and aortic aneurysm in 4 cases each, andsepticemia in 3 cases. Among the 5 cases of facial injury,each patient showed prostatic adenocarcinoma, abruption,septicemia, or no underlying disease. In the remainingcases, Morimoto et al. [17] did not discuss the causativeunderlying disease. The present patient had no medical his-tory before the traffic accident and preoperative hemostaticfunction tests yielded normal results. Two reasons couldexplain DIC in the present case. One is septicemia associatedwith severe postoperative systemic inflammatory responsesyndrome (SIRS). Postoperative stress seemed to not onlyinduce SIRS but also increase its severity. Under severe SIRS,DIC may have developed from hypercoagulability because of

4 Case Reports in Dentistry

Table2:DIC

relevant

tooralandmaxillofacialsurgery.

Num

ber

Author

Year

Age

Sex

Surgery

Und

erlyingdisease

Progress

1Falace

andKe

lly[5]

1976

85M

Extractio

nof

6anterio

rteeth

Occultp

rosta

ticadenocarcino

ma

Alive

2Ra

wsonetal.[6,7]

1976

45F

Extractio

nof

athird

molar

andsubm

andibu

lara

bscess

Septicem

iaDead

3Samman

[3]

1984

28F

Forehead,lip,and

tong

uelaceratio

nfro

mtraffi

caccident

Abruption(38-weekpregnancy)

Alive

4McK

echn

ie[8]

1989

59M

Extractio

nof

maxillaryfirstmolar

Occultp

rostaticadenocarcino

ma

Dead

5Ch

ishiro

[9]

1989

86M

Extractio

nof

maxillarymolar

Know

nabdo

minalaorticaneurysm

Dead

6Marshalletal.[10]

1993

24F

Extractio

nof

3third

molars

Unk

nown

Dead

7Cu

rrieandHo[11]

1993

31M

Acuted

entoalveolar

abscess

Septicem

iaDead

8Ch

ristia

nsen

andSoud

ah[12]

1993

19M

LeFo

rtIo

steotom

yNon

eAlive

9McLou

ghlin

etal.[13]

1994

62M

Lower

liplaceratio

nOccultp


ma,multip

lebo

nemetastases

Alive

10HeroldandFalworth

[14]

1994

73M

Extractio

nof

upperc

anine

Occultabd

ominalaorticaneurysm

Alive

11Mehra

etal.[4]

1997

65M

Scaling,parotitis

Unk

nown

Alive

12Sawakietal.[15]

1999

62M

Extractio

nof

maxillaryprem

olar

andmolar

Occultp


ma,multip

lebo

nemetastases

Alive

13Cb

oetal.[16]

2001

28F

Fracture

ofmandible

Non

eAlive

14Morim

otoetal.[17]

2001

37F

Infectionaft

ertoothextractio

nUnk

nown

Alive

15Morim

otoetal.[17]

2001

25M

Multip

leinjurie

softhe

mandible

Non

eAlive

16Ita

etal.[18]

2001

22F

Extractio

nof

mandibu

larthird

molar

KTW

synd

rome

Alive

17Petersetal.[19]

2005

82M

Extractio

nof

anterio

rtoo

thAo

rticaneurysm

Alive

18Im

aietal.[20]

2010

88M

Spon

taneou

shem

orrhage

Aorticaneurysm

Alive

19Ozakietal.

2016

21M

Multip

lefacialinjury

from

traffi

caccident

Septicem

iaAlive

Case Reports in Dentistry 5

abnormally high activity of a chemical mediator [22]. Theother is persistent intraoral and nasal hemorrhage after theaccident. Laboratory testing showed prominent decreases inhemoglobin (14.7 g/dL to 7.3 g/dL) and platelets (23.8× 104/𝜇Lto 9.8 × 104/𝜇L) between the first visit and the surgery. DICwas possibly triggered in the patient from the large volume ofblood loss, consumption of platelets and coagulation factorsby acute massive hemorrhage, and a high volume of bloodtransfusionwithin a short period [22, 23]. Under such generalconditions, the patient had already been in a chronic stateof DIC before surgery, and this served to aggravate thesymptoms.

The occurrence of DIC is difficult to predict in casesinvolving young patients with no underlying disease, asin the present case. Over the last 20 years, no fatal casesof DIC have been reported in association with oral andmaxillofacial surgery (Table 2).Therefore, in cases with facialinjury, symptoms must be detected and progression of DICprevented by careful perioperative management.

Consent

Informed consent was obtained from the patient for publica-tion of this case report and accompanying images.

Competing Interests

Theauthors declare that there are competing interests regard-ing the publication of this paper.

References

[1] J. A. Spero, J. H. Lewis, and U. Hasiba, “Disseminated intravas-cular coagulation. Findings in 346 patients,” Thrombosis andHaemostasis, vol. 43, no. 1, pp. 28–33, 1980.

[2] H. Wada, J. Thachil, M. Di Nisio et al., “Guidance for diagnosisand treatment of disseminated intravascular coagulation fromharmonization of the recommendations from three guidelines,”Journal of Thrombosis and Haemostasis, vol. 11, no. 4, pp. 761–767, 2013.

[3] N. Samman, “Disseminated intravascular coagulation and facialinjury,” British Journal of Oral andMaxillofacial Surgery, vol. 22,no. 4, pp. 295–300, 1984.

[4] P.Mehra, A. Caiazzo, and J. Cataudella, “Disseminated intravas-cular coagulation associated with parotitis: a case report andreview,” Journal of Oral and Maxillofacial Surgery, vol. 55, no.12, pp. 1478–1482, 1997.

[5] D. A. Falace andD. E. Kelly, “Disseminated intravascular coagu-lation and fibrinolysis as a cause of postextraction hemorrhage.Report of a case,” Oral Surgery, Oral Medicine, Oral Pathology,vol. 41, no. 6, pp. 718–725, 1976.

[6] D.W. Rawson, J. B. Harrison, C. C. Alling, andM. K. Hamilton,“Clinicopathological conference. Case 13, part 1,” Journal of OralSurgery, vol. 34, no. 1, pp. 62–63, 1976.

[7] D.W. Rawson, J. B. Harrison, C. C. Alling, andM. K. Hamilton,“Clinicopathological conference. Case 13, part 2. Disseminatedintravascular coagulation,” Journal of Oral Surgery, vol. 34, no.2, pp. 173–177, 1976.

[8] J. McKechnie, “Prostatic carcinoma presenting as a haemor-rhagic diathesis after dental extraction,” British Dental Journal,vol. 166, no. 8, pp. 295–296, 1989.

[9] T. Chishiro, “A case of disseminated intravascular coagulationthought to be caused by tooth extraction in the hypercoagulablecondition due to abdominal aortic aneurysm,” Nippon NaikaGakkai Zasshi, vol. 78, no. 12, pp. 1777–1778, 1989.

[10] D. A. S. Marshall, C. Berry, and A. Brewer, “Fatal dissem-inated intravascular coagulation complicating dental extrac-tion,” British Journal of Oral and Maxillofacial Surgery, vol. 31,no. 3, pp. 178–179, 1993.

[11] W. J. R. Currie and V. Ho, “An unexpected death associated withan acute dentoalveolar abscess—report of a case[a/t],” BritishJournal of Oral andMaxillofacial Surgery, vol. 31, no. 5, pp. 296–298, 1993.

[12] R. L. Christiansen and H. P. Soudah, “Disseminated intravas-cular coagulation following orthognathic surgery,”The Interna-tional Journal of Adult Orthodontics and Orthognathic Surgery,vol. 8, no. 3, pp. 217–224, 1993.

[13] P. McLoughlin, S. Chen, and J. G. Phillips, “Disseminatedintravascular coagulation presenting as perioral haemorrhage,”British Journal of Oral and Maxillofacial Surgery, vol. 32, no. 2,pp. 94–95, 1994.

[14] J. Herold and M. A. Falworth, “Disseminated intravascularcoagulopathy presenting as a bleeding tooth socket,” BritishDental Journal, vol. 177, no. 1, pp. 21–22, 1994.

[15] Y. Sawaki, M. Yamada, Y. Kasuya, and M. Ueda, “Disseminatedintravascular coagulation presenting as hemorrhage after toothextraction,” Journal of Oral andMaxillofacial Surgery, vol. 57, no.3, pp. 341–344, 1999.

[16] Y.-S. Cbo, K.-W. Kim, and S.-N. Yang, “Disseminated intravas-cular coagulation after a surgery for a mandibular fracture,”Journal of Oral and Maxillofacial Surgery, vol. 59, no. 1, pp. 98–102, 2001.

[17] Y. Morimoto, M. Ikeuchi, K. Yamamoto, T. Kirita, and M.Sugimura, “Clinical study of disseminated intravascular coag-ulation in oral and maxillofacial regions—predictors of onsetand prognosis,” Oral Diseases, vol. 7, no. 5, pp. 291–295, 2001.

[18] M. Ita, M. Okafuji, Y. Maruoka, and F. Shinozaki, “An unusualpostextraction hemorrhage associated with Klippel-Trenaunay-Weber syndrome,” Journal of Oral andMaxillofacial Surgery, vol.59, no. 2, pp. 205–207, 2001.

[19] K. A. Peters, P. T. Triolo Jr., and D. L. Darden, “Disseminatedintravascular coagulopathy: manifestations after a routine den-tal extraction,”Oral Surgery, OralMedicine, Oral Pathology, OralRadiology and Endodontology, vol. 99, no. 4, pp. 419–423, 2005.

[20] T. Imai, M. Michizawa, H. Shimizu, Y. Yura, and Y. Doi, “Spon-taneous intraoral hemorrhage as manifestation of thoracoab-dominal aortic aneurysm-associated disseminated intravascu-lar coagulation: case report and review,” Journal of Oral andMaxillofacial Surgery, vol. 68, no. 1, pp. 195–200, 2010.

[21] S. Gando, T. Iba, Y. Eguchi et al., “A multicenter, prospectivevalidation of disseminated intravascular coagulation diagnosticcriteria for critically ill patients: comparing current criteria,”Critical Care Medicine, vol. 34, no. 3, pp. 625–631, 2006.

[22] R. I. Handin, “Disorders of platelet and vessel wall,” in Harri-son’s Principles of Internal Medicine, K. J. Issel Bacher and E.Brauwald, Eds., pp. 1798–1804, McGraw-Hill, New York, NY,USA, 13th edition, 1994.

[23] H. Wada, K. Minamikawa, Y. Wakita et al., “Hemostatic studybefore onset of disseminated intravascular coagulation,” Amer-ican Journal of Hematology, vol. 43, no. 3, pp. 190–194, 1993.

Submit your manuscripts athttp://www.hindawi.com

Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

Oral OncologyJournal of

DentistryInternational Journal of



International Journal of

Biomaterials


BioMed Research International


Case Reports in Dentistry


Oral ImplantsJournal of


Anesthesiology Research and Practice


Radiology Research and Practice

Environmental and Public Health

Journal of


The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014


Dental SurgeryJournal of

Drug DeliveryJournal of



Oral DiseasesJournal of


Computational and Mathematical Methods in Medicine

ScientificaHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

PainResearch and TreatmentHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

Preventive MedicineAdvances in


EndocrinologyInternational Journal of



OrthopedicsAdvances in

case report disseminated intravascular coagulation after...

Documents